Selected and reviewed by James Park,
advocate of the right-to-die.Organized in the
order of quality, beginning with the best.
Summaries of the contents are presented in black.
Comments and responses by this reviewer are presented in red.

A suicide-prevention
psychiatrist turns a critical eye
on the Dutch experience of voluntary death assisted by a physician
and merciful death chosen for patients
no longer able to give consent.
Hendin believed that too many abuses and
mistakes
were taking place in the Netherlands
—and that the U.S. should not
copy the pattern
created by the Dutch.
Rather, we should provide better pain-control,
so that patients will not request death.

Hendin discusses
several cases of physician-assisted death
in which serious doubts could be raised:
In one case a woman was suffering
because
of the loss of two sons to death
and the loss of her husband by divorce.
She had no further reasons to go on living.
When, after many attempts at psychological
help,
all agreed that nothing was going to change
her wish to be dead,
she was granted her wish to die on the basis
of her mental suffering.

On the basis of such
cases and other controversial reports,
Hendin claims that the Dutch guidelines for
voluntary death
with the assistance of a physician were routinely
ignored.
Doctors were often doing what they thought best
—including shortening the process of dying—
without explicitly asking the patient or
family
if death is the best choice.

The best response
to the worries
and doubts raised in this book
is not to ban all voluntary death and merciful
death
but to create safeguards
that are more reasonable
and workable
than those originally used in the Netherlands.

For example, reporting assisted dying to the prosecuting authority
after the death
had already taken place
made no sense.
The Dutch police and prosecutors could not bring
anyone back to life.
They could only punish the doctor for doing
something illegal.
(What incentive does a doctor have to report
assisted deaths,
if no good can come
of such reporting
and the doctor might even be prosecuted?)
Furthermore, law-enforcement officials
have no training or expertise
in the complex issues of making end-of-life medical choices.

Any such reviews
by the prosecutor should
be completed before
the voluntary death or merciful death takes
place.
Then everyone involved can proceed with the
knowledge
that no prosecutions will result from their
decision
to proceed with a wisely-chosen death.

(Since this book was published,
the Dutch system has been changed a few times.
Now instead of reporting to the police or the public prosecutor,
doctors are supposed to report their cases of chosen death
to Regional Review Committees
each of which has a lawyer, a doctor, & an ethicist.
Only a few cases each year are forwarded to prosecutors.)

Hendin points out
that the second doctor's professional opinion
is often routine and superficial,
based more on the first doctor's reputation
and opinion
than on an independent assessment
of the
condition of the patient.
A better system could be created
to ensure
that the second
professional
opinionis truly independent and designed
to correct
any
mistakesin the diagnosis
and
prognosis of
the first
doctor.

Carefully considered
waiting periods should be required.
Often patients ask for assistance in dying
immediately after learning that they have
a terminal disease.
But many who were prevented
from killing
themselves
immediately after they were told about
terminal illness
have gone on to live for a number of additional
years.

Should a long-married
couple be permitted to die together?
This would save either spouse having to grieve the
loss of the other.
But sometimes the dominant partner (often
the husband)
is forcing the other partner to go along
with a 'suicide pact'.
Careful
safeguards
would examine
all options,
including the option of dying
together.
But the physical condition of the
healthier
partner
should also be taken into account.
Here is a chapter by this reviewer
explaining how to counteract family pressure to 'choose' death,
including the danger of 'suicide pacts': Protecting
Patients from Family Pressure to Die.

Another problem of
the Dutch system is the requirement
that the patient
remain fully
conscious and capableup until the moment of death.
This leads to some premature
deathsbecause the dying patients
sometimes fearthat they will not be sufficiently
lucid or rational
laterto be able to consent
to
voluntary
death
with assistance.

The solution to this
dilemma is for the patient
to draw up a written request
for death—created when the patient was clearly in
full possession
of his or her mental capacities.
This plan for death would specify what should happen
if and when the patient becomes unconscious
or otherwise loses the capacity to make medical decisions.
Such prior documented requests
for
deathshould be honored everywhere in
the world.
Proper safeguards would make sure
that the
prior request for death
was made while the patient was
still clearly
capable
of making a wise decision about
the timing
and means of death.
A well-documented advance request
for death
once a certain point in mental
decline has
been reached
would remove most doubts in the
minds of
doctors and proxies
who now must make decisions for
patients
who have progressed
beyond being able to
make their
own life-ending decisions.
This would solve the problem in
the Netherlands
sometimes called "assisted
death
without
explicit
request".

Some Dutch doctors
(as doctors everywhere)
provide slight assistance in the dying process,
such as increasing
pain medication,
in order to avoid going thru the formal process
of applying for an approved voluntary death.
Such life-ending decisions produce a slower
death.
And such deaths are always reported as
"from natural causes",
rather than cases of voluntary death with
physician assistance.
A more user-friendly system of
safeguards
would work better in such cases,
thereby avoiding some premature
deaths that
result
from secretive—often unarticulated—decisions
to shorten the process of dying.

Hendin usually considers
the worst possible interpretation
of each of the cases and
situations he considers.
But such maximum skepticism must
be considered
by all advocates of the
right-to-die.
We must be able to address problemsthat will be raised by rather rare
and unlikely
scenarios.
Wise safeguards are needed for the
marginal
situationsabout which reasonable persons of
good faith
can disagree.
When we are in doubt about the
wisest course
of action,
we need a deeper investigation of
the actual
situation
and a fuller exploration of all
the alternatives
other than death.
Opponents of the right-to-die will
use such
marginal cases
to support their position that all chosen death
must be outlawed
because of the
possibility
of mistakes and abuse.
No one should be put to
death for the convenience of others.
Some disabled
people
fear this the
most.
Can we create wise safeguards that are so comprehensive
that even (open-minded) disabled people
will endorse them?

The title of Hendin's
book—Seduced
by Death—
points to the danger of society
too easily affirming the 'right-to-die'.
If we create a 'culture of death', irrational suicides will increase,
because people who have foolish 'reasons'
for killing themselves
will get the mistaken impression that the
society approves
of their 'decision' to commit irrational
suicide.
Because Dr. Hendin has devoted his professional
life
to preventing irrational suicide,
he is acutely aware of the dangers created
by glib talk about the 'right-to-die'.

In affirming
our right-to-die, we
must avoid
romanticizing death.
Voluntary death and merciful death
should
not be the first optionpeople consider when confronting
difficult
problems in life.
Rather, a wise and rational ending
of life
should be the last resort.

When he wrote this book, Wesley Smith was
the attorney for the International
Anti-Euthanasia Task Force,
one of the strongest opponents of the right-to-die in the United
States.

Like any good lawyer, Smith builds his case by
citing situations
in which people took their own lives prematurely—people who were assisted in dying
before it was necessary
and former persons whose lives were ended by others
before they would have died from natural causes.
Smith wants to combat the worst
abuses of
the so-called "right-to-die" by banning most life-ending
decisions.

If society turns against the media-promoted cult of
death,
then a few more premature deaths could be prevented.
Loud talk about the "right-to-die" encourages some people
with flimsy 'reasons' for ending their lives to kill themselves.

Smith presents a very low threshold for continuing
life-supports:
If the patient is still a living human being, no one
should 'pull the plug'.
In other words, on most (perhaps all) of the famous right-to-die cases,
he would have argued to keep the former person 'alive'
even tho he or she was in a persistent vegetative state.
Human life should be granted sanctity no matter what its quality.
All human life should be preserved as long as technologically possible.

'Anti-euthanasia' advocates realize that one of the
most common ways
for life to be mercifully terminated is to remove life-support systems.
This method of managing dying is well-established in law and
practice.
The last-ditch resistance focuses on food and water:
If nutrition and hydration are provided by means of tubes,
then it looks like a medical
treatment or a
life-support system.
As medical treatments or
procedures, such tubes can be withdrawn.
But if they are defined as comfort
care (like keeping the patient warm),
then they cannot be withdrawn or withheld.

If the
'anti-euthanasia' advocates had their way, food and water could never
be withdrawn or withheld—as long as the body is still
'alive'. But it does not seem likely that
such views will prevail. Just as fully-capable patients canrefuse
food and water,similar choices can be taken
for patients who can no longer decide. As least this means of merciful
death can be usedwhen the patient has left a
written statement requesting
death
when specified
conditions develop.

According to the 'anti-euthanasia' advocates,
all efforts to expand the 'right-to-die' must be resisted
because of the slippery
slope:
If we allow relatives of former persons in PVS to 'pull the plug',
we will not be able to stop the rampage of killing.
The next people killed without their consent will be the disabled
and others who can no longer contribute anything to society.
Every disabled person will be at risk
if we allow further advances of the 'right-to-die'.

Lest this reviewer be suspected of exaggerating
Smith's position,
here is a quote from the bottom of page 50:
"Yet virtually every day, fellow humans are being deprived
of the basics required for life just because they are disabled."

Lawyers tend to
over-state their casesbecause it has some persuasive
power for the listeners. Smith wants to classify Nancy
Cruzan as "cognitively disabled", even tho she was in a persistent
vegetative state. Few people want to discriminate
against the disabled. But if a former person will never
have another thought or feeling, why keep that body 'alive' on
'life-support' systems?

Smith does correctly warn against hasty diagnoses:
One patient who was thought to be permanently unconscious
woke up a week later and made a complete recovery.

Death-by-dehydration
is another important theme
in the anti-euthanasia movement.
Smith claims that death by means of withdrawing fluids is terrible.
He quotes one doctor who told him so in a private interview.
No further evidence is offered.

Death-by-dehydration will have to
be studied and documented much more fully
before the position taken by the anti-euthanasia
advocates will be sustained. This reviewer thinks the opposite
will be shown:That death-by-dehydration
is a good way to end of one's life.
Here is a website supporting Voluntary
Death
by Dehydration.

Smith points out that we would not cause
the deaths of dogs or horses by dehydration.
Why cause additional days of suffering?
When we decide that the end has come for animals,
we easily give them a lethal injection.

Smith warns that we will do the same for human
beings:
If we allow death-by-dehydration,
why not shorten the
process by giving a lethal injection?To avoid sliding down
the icy sidewalk on a hill,
we should avoid even getting close to that hill. This means no
death-by-dehydration.

Another common argument from the anti-euthanasia
movement
invokes the specter of Nazi Germany,
which also used the concept "euthanasia".
'Undesirable' people were put to death in concentration camps.
These included Jehovah's Witnesses and labor union leaders.
But most of the victims of the Nazi Holocaust
were killed merely because they were Jews.

The Nazis also wanted to get rid of
"useless eaters".
If the disabled and the dying could no longer contribute,
then they should be sent to the gas chambers.

The Nazi crimes
committed under the name of
"euthanasia"should never be associated with
the right-to-die. The
victims of the Nazi killings had no choice.They were killed for economic,
political, & racist 'reasons'.

Smith thinks that we should learn from the Nazi
Holocaust
that we should never permit doctors to assist people in dying:
Just see what happened in Germany during the Nazi period.

Such arguments
have a strong emotional appeal. And there are probably some
lessons we can learn from Nazi atrocities. Safeguards are needed to prevent
anything even vaguely similar to the
Holocaust
from ever happening again.

Because
opponents of the right-to-die often use the Nazi Holocaust,
we who believe in the right-to-die
should be ready to answer the questions raised by the Nazi
atrocities during the Second World War.Strong
and
reasonable safeguards
are needed to prevent any killing for economic, political, or racist
'reasons'.

The next chapter deals with the Dutch experience
with euthanasia.
In the Netherlands, doctors are supposed to follow guidelines
in helping their patients to die.
But frequently they perform euthanasia with shortcuts.
For example, they sometimes ignore the requirements
for repeated requests for death from the patient
because the patient is already too far gone to make another request.

In this
reviewer's mind, this illustrates the need
for safeguardsthat can take such situations into
account: When the patient has become incapable of making medical
decisions,then specific proxies should be
empowered to make such choices,including the decisions that will
end that patient's life. These proxy decision-makers should
be selected by the patient before he or she loses the power
to make wise end-of-life choices.

Smith cites some foolish reasons for wanting death:
a scar on one's face, fear of overeating,
fear of future health problems caused by AIDS,
& untreated psychological problems.
When doctors have the power to decide death, mistakes will
happen.

Also under Dutch law and practice,
parents of defective
newborns can request death for them.
If they can find a doctor who agrees, death will be the result.
Smith does not think it should be that easy.
He cites disabled people who are glad they were not killed in
infancy.

In several chapters, Smith warns against the
so-called "right-to-die"
as a form of oppression
against the most vulnerable in any society.
The poor, the homeless, those who cannot explain their wishes,
the most difficult patients who have no one to speak for them,
racial minorities, illegal aliens, criminals, etc.
are all in danger of being put to death if 'death culture'
advances.

Sometimes doctors might be tempted toward euthanasia
in order to prevent malpractice suits.
The doctor might hope to cover
up a mistake.
And if the patient is dead,
any economic award won in court will be much less
than if the patient will need life-long care.

Disabled people are among the strongest opponents
of the so-called "right-to-die".
They fear that people who can no longer contribute to society
will be killed first whenever any "right-to-die" is allowed.
So they think that the best way to protect themselves
in to resist all advances toward a 'death culture'.
All forms of chosen death should be prohibitedbecause
of the
danger to vulnerable people.

This reviewer
agrees these worries should be
taken seriously. We do have the historical
example
of Nazi Germany,where disabled people were put to
death as "useless eaters". Such things are not likely to
happen again. But good safeguards will make it
absolutely certainthat disabled
people
will not be
coerced or manipulated into death.

The
right-to-die movement should seek to create
safeguardsthat will be approved even by
disabled persons. Here is one example of a
safeguard especially for disabled
people: When a disabled person creates a
Medical Care Decisions Committee,he or she could make sure to
include disabled persons
in that MCDC.
Or an ethics committee of a
hospital or nursing homecould be sure to include disabled
persons on that committee.
Where medical decisions are routinely made for disabled persons,there could be a regular committee
consisting
entirely of other disabled persons.
Of course, these would have to be
open-minded disabled people,who are capable of going either
way on questions of life or death.
If a committee of disabled persons
always said "no" to all proposed life-ending
decisions, then, of course, there would be no
point in having such a committee.

When able-bodied people try to make decisions for
the disabled,
they often bring their own preconceptions to the process.
For example, if they could not imagine themselves
wanting to live with such severe limitations,
they might suggest death as an alternative to life-with-disability.
But people who have already adjusted to disability
realize that it is entirely possible to have a meaningful life
even with a disabled body and/or mind.

Disabled persons might not be the only victims of a
'death culture'.
Sometimes a spouse wants to be free of responsibility
for a husband or wife who has become more a burden
than someone who is loved and cherished.
If too-easy choices for death were permitted,
spouses might use the "right-to-die"
as a means of freeing themselves of unwanted relationships.

In Chapter 8, Smith attempts to answer
several arguments for the right-to-die.
After each argument favoring the right-to-die is rebutted by Smith,this reviewer offers a reply from
the perspective of the right-to-die.

(1)
Opposition to the right-to-die is primarily religious. Therefore the separation of
church and state
should permit secular persons to choose death. Smith cites non-religious people who oppose the
right-to-die.

Right-to-die
reply: People who object of choosing
death on religious grounds should
follow
their own
consciences. But they should not attempt to
impose their morality on the whole society by means of
the law.

(2)
Safeguards will prevent abuses and mistakes.
Smith cites the Netherlands and Nazi Germany
as places where safeguards have been circumvented.
He believes that safeguards
will never work.

Right-to-die
reply: The question of safeguards will be
central to the next decades of debate
about the right-to-die.
Thoughtful advocates of the right-to-diemust create
safeguards that will work so
wellthat even some of the opponents of
the right-to-diewill eventually embrace such
safeguards.
At least many people in the middle
will embrace workable
safeguards.

(3)
Voluntary death and merciful death will only be used as a last resort.
Smith says that it is never
necessary to hasten death.
Better hospice care and pain-control will eliminate all requests for
death.

Right-to-die
reply: Yes, all appropriate medical care
should always be tried first. Death
should never be suggested as
a substitute for medical
care.But there might come a
turning-point in many slow deathswhen shortening the process of
dying would be better in the eyes of all
concernedthan keeping the body 'alive' as
long as technologically possible. Good safeguards will eliminate
even the suspicionthat someone is being rushed into
deathinstead of being offered
appropriate medical care.
Prohibiting the right-to-die does
little to
improve end-of-life care. Voluntary death and merciful death should only be considered after all appropriate medical
treatments have been tried.
Safeguards can ensure that all
relevant
medical options
have been explored.

In extreme cases, when cure is no longer possible,
Smith does endorse terminal
sedation,
which will keep the patient unconscious until natural death.
In his view, being unconscious for the last few days
is better than being poisoned.

(4) When
animals are terminally ill or hopelessly injured, we have no problem "putting
them to sleep". Why do we lack similar
compassion for suffering human beings?
Smith points out that we have always separated
killing animals from killing people.
We should not use veterinary ethics for persons.

Right-to-die
reply: Yes, we should certainly give up
this analogy. No human person wants to be
treated like an animal. What we want is wise and
compassionate treatment as we bring our
distinctively-human lives to a close.

(5) Some
advocates of choices at the end of lifeare also advocates of choices
at the beginning of life:They approve of the right to
have an abortion.

Right-to-die
reply:Yes reproductive freedom should be separated from the
right-to-die. Different values are being
protected in these
different
situations.

(6) The
majority of the population favors the right-to-die.
Smith disputes this claim by pointing out
that such poling can easily be distorted by how the question is
asked.
The majority of people do not
favor doctors helping patients to die.
And Smith points out the many failures of referenda on the right-to-die
when the question was put to a yes/no vote of the people.

Right-to-die
reply: Public opinion is moving slowly in
the direction of the right-to-die.
More high-profile cases of former
persons kept 'alive' by machineswill convince more people to favor
choices to end 'life' voluntarily. And the people who will never
agree to any form of chosen deathwill not be forced to participate.
For the foreseeable future,
'natural death' will always be an
option.

(7) The
right-to-die is needed because too many people are being kept
alive on machines for too many months before they
die.
Smith says that the appropriate answer to this problem
is better Advance Directives and better implementation of them.
An Advance Directive should specify
when life-support is appropriate and when it is not.
Smith argues that Advance Directives should not be rigid.
Unforeseen circumstances might call for a different response
than imagined in the Advance Directive for Medical Care.

Right-to-die
reply: Yes, better use of Advance
Directives will help all end-of-life
choices. And a very important part of any
Advance Directive is appointing the best proxies to
make decisions when the patient is not capable
of deciding. And comprehensive Advance
Directives should include discussion of the
right-to-die. People
who want the right-to-die
should say so.And people who want the maximum
permitted medical careshould express that wish just as
completely and explicitly.

(8) Only
conservatives oppose the right-to-die.
Smith disputes this claim by citing many people
who are very liberal on other issues
who nevertheless oppose any so-called "right-to-die".
Liberals also can fear the abuses that might follow
any liberalizing of the laws surrounding the process of dying.

Right-to-die
reply: It does not matter who is lined up
on either side. We want wise policy achieved by democratic means, based on reason.

(9) There
is no difference between pain-control and choosing death. Such advocates of the
right-to-die invoke the principle of double effect: Pain-control measures are
permittedas long as the primary intention is to relieve pain and not to
cause death,even if shortening the process
of dyingis a foreseeable consequence of
the pain-medication.

Right-to-die
reply: Only some advocates of the
right-to-die use this form of thinking. More forthright advocates say that
we should clearly separatedecisions that are intended to
relieve suffering(with the hope of returning the
patient to a normal life)from decisions that are intended to
end the patient's life.Even 'terminal
sedation' should be called a life-ending decision. And when life-ending decisions are
being considered,all of the safeguards should come
into play. If we play mind-games ("We are
only relieving suffering."),the value of safeguards for
life-ending decisions is lost.
If it is only a decision
about levels of medication,who will raise the question of
safeguards for life-ending
decisions?

Does it seem
to readers of this book-reviewthat Smith discusses only very
weak arguments for the right-to-die? Perhaps this is his lawyer's
method: Think only for one side. Never acknowledge that your
opponent has any valid ideas. Attempt to make the other side
look foolish. Present and reply only to the
weakest arguments of your
opponent.If you have discussed 9 arguments, the reader might get the
impression that you have looked at the whole
case for the right-to-die. Perhaps Smith has selected only
these 9 arguments because they give him occasions to
support his own point of view. Why has Smith not confronted the best arguments for the right-to-die? For example, where does Smith
discuss personal autonomy?

A balanced
book would allow each side to
present its best arguments,to which the other side would be
invited to reply.

Smith's preferred mode of death is a natural death
in a hospice.
We do not need to drink the hemlock.
Rather, we can get proper pain-control in a home-like setting.
And then we will never be interested in the right-to-die.

Will Wesley
Smith's views ever change? Perhaps not.
But some less committed anti-euthanasia advocates
might revise their views by reading
books
supporting the right-to-die. In any case, the issues
Smith
raises all need to be addressed,because they do in fact appear in
the minds of many people.

(Since this is the same author as the book just
above, this review will be somewhat
shorter, because the author makes many of
the same points again.)

A lawyer raises doubts about what he perceives as
a trend in modern medical ethics to decide in favor of death
rather than keeping patients
alive
as long as possible.

The major issues include:
giving up medical care 'too soon',
making value-choices regarding the quality of life,
mercy-killing and assisted suicide,
& pressuring people into dying so they can 'donate' their organs.

Smith has no
special expertise in the
field of medical ethics, but he wants to preserve or go
back towhat he conceives to be
traditional medical ethics.

Most of the
review that follows will consist of
replies to Smith. People who believe in the
right-to-die (as I do) should take the critics seriously,
especially those who base their
arguments on reasonrather than mere ideology. Smith does give the best arguments
he can construct for each of the points he wants to
make.

When Wesley J.
Smith criticizes a case of premature
death, he usually frames the choice in
life-or-death terms: These cases of 'mercy-killing' or
'euthanasia' should not have
happened. We should always choose life over
death. But as mortals, we do not have
those options. Rather, we must select death now or death later.
And we should ask how much better
a later death would be.

For example,
consider a former person who has been in a persistent
vegetative state for a number of years:
When there is no chance of
recovery, the
options are not life
or deathbut death this year or death in
some future year. What would be the best
year-of-death for this former person?

Smith has entitled this book Culture
of Death
because he fears that medical ethics is now becoming ideological.
And that new ideology will always favor death over life.
Or to put it more accurately, the new culture of death
will always favor death now over death later.
He gives examples to prove his case. And some of these examples do seem
to be premature deaths.
However, we do not hear the other
side of any of these cases. As a lawyer, Smith presents only
one side. In a court of law, the other side
would be given equal time.

And even if
there were a number of cases of
premature death,this does not mean that we should
outlaw all chosen death. Rather, it means that we need wise
and careful safeguardsthat have the potential to prevent premature deaths. Under any system of safeguards,
there will always be mistakes: Some lives will be ended too soon.
But under any system that
prohibits all chosen deaths, there will also be mistakes: Some individuals will be forced to
suffer too long before
death. And if these patients no
longer suffer because they are
unconscious,those who care about them might be
forced to endure seeing them imprisoned by machines that are keeping them
'alive'.

All colors of
medical ethics should be permitted in
a free society. Some patients and proxies will
choose a later death. And other patients and proxies
will choose an earlier death.
Within reason, both options should
be available.

Smith fears that a new elite of medical ethicists is
emerging,
who have an ideology that says:
"When in doubt, always choose death now rather than death
later".

I do not see
any such
culture-of-death emerging. Ethical views of all colors are
heard and heeded.
Do conservatives or liberals have the upper hand? A case for either claim can easily
be made by selecting only examples that
support the chosen claim.

Smith deplores the fact that medical ethics
is no
longer based on religious belief.
When the 'sanctify of life' prevailed, then all life
(no matter what its quality) was preserved as long as possible.
Smith fears that if we 'devalue' some forms of life, we will not know when to stop.
If we allow some forms of voluntary death or merciful death,
then other individuals with
a low quality of life are in danger.

This is simply
a foolish and absurd claim. Even ordinary people who have no
training in medical ethicscan make quality-of-life choices
for themselves—and for the former persons they
have loved. Permitting
some
life-ending choicesdoes not mean that we will always
'pull the plug'.

In everyday
medical practice, religious
views are taken into account. And religious beliefs about life
and death should always be honored whenever
possible. But religious beliefs should not
dictate futile
medical
care.Some religious people
believe that prayer
will bring a
cure. If they pray hard enough, God will
perform a miracle. Nothing in medical practice should
prevent praying.
But should there be practical
limitson how long to wait for a
miracle?Hospitals should not be required to keep hopeless bodies
on
'life-supports' indefinitely,
waiting for a miracle. Let religious practices be
parallel to medical practices. But do not let one dictate to the
other.

Smith worries that bioethics sometimes
makes wrong decisions:
Some doctors recommend non-treatment for defective newborns.
Late-term abortions should not be permitted.
Sometimes medical experiments are performed on human subjects
without those subjects fully understanding the dangers.

Advocates of
the right-to-die would reply: Each example of a questionable
decision in medical ethicscould have been handled by better
safeguards —and a more thoro application of
safeguards already in place. The problems Smith cites call for better
medical ethicsrather than for prohibiting
the practices he discusses.

Has the principle of autonomy gone too far?
Sometimes people wish to die when they get a terminal diagnosis.
But if doctors refuse to cooperate with irrational suicidal urges,
some of these patients change their minds about dying.
Paternalism is justified by the good results sometimes
achieved.
For example, sometimes the patient
might be hurried into choosing death mainly to benefit the family,
who will be freed
of the burden of caring for the patient
and who might inherit
large sums of money.
Careful safeguards surrounding all
life-ending decisions should be able to prevent almost
all mistakes and abuses. Smith has performed a valuable
service for everyone considering the
option of choosing death: He has gathered doubtful cases—situations in which valid
questions can be raised about the wisdom of choosing death
at the time it was chosen.

Another chapter explicitly addresses the possibility
that discussing the 'right-to-die' will create a duty-to-die.
Medical ethics uses the concepts of futile medical care and rationing.
Sometimes patients and their loved ones demand medical
treatments
that have little or no chance of being effective. Medical ethics does
consider the cost and benefit of each procedure.
Smith does not think that money should ever be considered.

The state of
Oregon created a
priority list of
treatments. Public funds went only for
the procedures higher on the list.
Treatments with high cost and little benefitwere not offered to people
who could not pay. Each year the cut-off point was
adjusted to fit the money available. This system of rationing assured
that simple and
less-expensive treatments were available to everyone. But it did exclude complex and
expensive treatments. Thus, some people did die sooner
because the public would not pay for
their treatment. But many more people were saved
from simple causes of deathbecause in Oregon basic medical
care was available to all.

Smith worries that the duty-to-die mentality
will be reinforced by the need for 'donated' organs for transplant.
Especially disabled people might be rushed into 'choosing' death
because it will benefit others who need their organs. Because of the possibility of
abuses and mistakes,is Smith suggesting that we terminate
organ-donation?

But a more
reasonable approach
would be to apply the safeguards already in
place more carefully. The public needs to be convinced
that the donors really were deadbefore any organs were taken.
Science fiction and sensational
journalism like to focus on the possibility of stealing organs from the living.Public willingness to
donate organs after death is very
fragile. A few reports of questionable
cases
(or cases that were not correctly
reported) can cause some people to revise
their plans for donating organs—either their own organs after
death
or the organs of family members who have died.
The public needs to understand brain-death more
fully.
Smith cites some cases when the diagnosis of brain-death was wrong:
The patient did recover and returned to normal life.

Thus,
independent doctors must
repeat the tests
to
make certain that the
patient
is really
brain-dead
before
considering donation. Understanding the specific way in
which this brain died and following the safeguards
for
proper waiting periodscan make the diagnosis of
brain-death more certain.

Some ethicists favor PVS being an optional
definition of death.
Smith does not agree: Persistent vegetative state is not death.
The public will rightly resist
such a re-definition of death. When the patient seems to be awake
part of the time,has reflex movements and breathes
without mechanical assistance,people without medical training
often have great difficulty understanding that this former
person will never recover.

Another proposed new definition of death
that Smith resists is permanent unconsciousness. Defective
infants is another possible source of
organs for other infants who will
otherwise also die. Especially when infants are born
with their upper brains missing,
these could be defined as born permanently unconscious.
Because anencephalic infants lack most of their brains,they will never have any
reaction, emotion, or thought. But if their organs
are working well, they
make ideal donors for other infants who were born
with defective hearts, for example.

Smith also opposes any form of organ-selling.
He worries that the poor will be exploited:
Instead of being offered full medical care,
their relatives will be offered cash for their organs.

This is not
likely to happen, but even the fact that people can conceive of such a practiceshows the need to have strong
safeguards to prevent
it. Organ-selling does present real
opportunities for abuse. So any organ-market should be
carefully controlled.

Smith also points out the dangers of surgically
removing organs
before the donor has been officially declared dead.

Even if the
donor has approved of
such a practice in advance,
we should never harvest organs from living bodies. No one associated with the present
system of organ-donationhas approved such a practice.
And it would be counter-productive
because it would feed
public
worries about stealing organs from the
living.
This is called the
dead-donor
rule.

Another element of modern medical ethics
that Smith disagrees with is the effort to limit 'futile' care.
Smith worries that it is too easy for doctors to declare
that further medical treatment would be useless.
According to Smith, economic and quality-of-life factors
should not be
considered in making medical decisions.
Ethics committees should be subject to review and reversal—just like the decisions of judges.
And this would require making their deliberations
public.

Smith worries that 'medical dehydration'
will be used inappropriately against disabled people.
And defective infants should not be refused treatment
merely because they will have lives of low quality.

In summary, Smith has constructed the best arguments
he can think of to prevent medical ethics from devaluing human life.
All human life is equally valuable and should be
protected.

In the first
few decades of the
21st century, the most likely arena of this
debate will be patients in PVS
and other patients who are permanently unconscious. Smith always wants to keep such
patients
'alive'.
Everyone who affirms the right-to-die will have to confront the
arguments presented in Culture
of Death.

This is a
collection of articles and essays by several different authors,all pointing out problems with the
right-to-die such as the physician aid-in-dying now
available in several states.Johns Hopkins University Press also
published a similar collectionthat took the opposite point of view: Physician-Assisted
Suicide: The Case for
Palliative Care and Patient Choiceedited by Timothy E. Quill, MD &
Margaret P. Battin, PhD.This book is reviewed in the companion
bibliography:Books Supporting the Right to Die:https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/B-RTDIE.html.

A professor of law
examines all of the issues surrounding euthanasia and physician-assisted
suicide.
Civilization should not
permit the purposeful ending of human life.
But all forms of making end-of-life decisions
within standard medical care should be permitted.

Some chapters carefully analyze the process
of withdrawing
medical treaments—including
life-supports—
as a permitted method of choosing death,
even if that life could have been extended indefinitely
if the life-supports were continued.
This is allowing nature to
take its course rather than euthanasia.

Another method of dying permitted within modern
medical care
is increasing
pain-medication with the knowledge
that such additional drugs in the patient's system
will probably shorten the process of dying.
This also is a recognized, standard method of choosing death,
entirely within the normal practice of medicine
and it should not be labeled euthanasia or physician-assisted
suicide.

She briefly mentions terminal
sedation,
recognizing this also as a valid and legal end-of-life treatment
that leads inevitably to the death of the patient.
Keeping the patient asleep until death comes
is also not a form of
euthanasia or physician-assisted suicide.

Because this
book was put together from a set of articles published over a few decades,
there is some repetition and some chapters that have little
to do with the right-to-die.

But it does
show an opening in the thinking of people opposed to euthanasia and
physician-assisted dying. Some opponents do allow medical
methods
of choosing death. "Just say NO!" is no longer a
useful response to the right-to-die.

This book is written
mainly in the voice of Mary Schindler—mother
of Terri Schiavo.
But Terri's father Bob, sister Suzanne, & brother Bobby
all have major comments included.
These four people are Terri Schiavo's family of origin.
And they were united in their opposition of allowing Terri Schiavo to
die.

Terri Schiavo's husband—Michael
Schiavo—has
written another book—Terri: The Truth—which
takes a very different perspective
on the facts and opinions surrounding the Terri Schiavo case.
Michael Schiavo's book is reviewed
in the bibliography Books
Supporting
the Right-to-Die.

This reviewer will leave it to careful readers to
decide
just where the objective truth lies between these two different
accounts.Even tho each book spins
the 'facts' to favor a particular belief,Michael Schiavo's book is probably
closer to what really happened.
And after many years of battling in courts,
the husband's perspective finally prevailed:
Terri Schiavo had her feeding-tube removed after 15 years in PVS.

The Schindler family members consistently 'see' more
responses
from Terri Schiavo than observed by most medical
experts.
And they found their own experts to support their observations.
The Schindlers always wanted to keep Terri alive
and to seek rehabilitation for her
so that at least some moments of awareness would be possible.

And after Terri's final death in 2005,
the Schindlers established a foundation
to support patients who have lost many mental capacities.
They hope that the tragic case of Terri Schiavo
will make it possible for other patients like Terri to be kept alive,
who would otherwise be declared "vegetative" and allowed to die.

The rhetoric of this book displays its point-of-view.
Disconnecting Terri's feeding-tube is consisting called
"starving and dehydrating" Terri.
The judge and the husband who chose this course of action
after it was determined to be what Terri would have chosen for herself
are called "murderers".
The most extreme statements by the Schindlers
say that the judge and the husband should both be in jail.

The Schindlers were able to find their own Roman
Catholic priests
to support their position that life-support should always remain in
place
until natural death occurs despite
the life-supports.
(In his book, Michael Schiavo notes that Mary
Schindlerdid authorize the removal of her
own mother from life-supportsat the end her mother's life.But the experience of dealing with
her daughter's death might have changed Mary
Schindler's mind about life-supports.)As the media began to pay attention to
Terri Schiavo,
many right-to-life groups came to side of the Schindlers.
In many ways Terri Schiavo became their poster-child.
The demonstrators and public opinion
were largely on the side of keeping Terri 'alive'.

The Florida legislature passed 'Terri's Law',
which allowed governor Jeb Bush to re-insert the feeding-tube,
even tho the courts had already decided she did not want it.
This law—which
was set to last only 15 days—was ruled unconstitutional because the
legislature
does not have the power to change rulings of the courts.

The U.S. Congress similarly tried to intervene
and the President signed a special bill,
but it also was
unconstitutional.

One take-home lesson from the Schiavo case
is that families can easily be divided about end-of-life choices.
No matter what evidence was collected by the courts,
even including the autopsy report,
the Schindlers continued to believe that Terri was alive and conscious
until she finally died in 2005 when her feeding-tube was removed.This shows the
power of metaphysical belief.The same people who believe that
an embryo has a soulbelieve that all remnants of life
must be preservedas human beings approach the end
of their lives.
The same difference of opinion will happen in other families:
Some family members will believe their dying relative is still a person.
And other family members will believe that this human individual has lost everything that made
him or her a person.Such possible
conflicts should be avoided
by each person creating an Advance Directive for Medical Care,
stating exactly what should happen in case of PVS
or some similar condition from which the patient will not recover.
The Schindlers will create one kind of 'living will',
which will keep them 'alive' as long as possible.
The Schiavos will authorize the withdrawal of life-supports
when there is no hope of recovery.

In the wake of the Terri Schiavo case,
many opponents of the right-to-die attempted to create state laws
that would mandate food and
water for all patients in PVS
unless there is clear and convincing evidence to the contrary.
This reviewer also read Michael Schiavo's book
in parallel—chapter-by-chapter with this book.
Michael Schiavo's book-—Terri:
the Truth—
is reviewed in the bibliography on Books
Supporting the
Right -to-Die.
Both reviews end with the following paragraph:

A good summary of
the historical background of the right-to-die debate,beginning in ancient times and brought
up to the present. This book is definitely against
"euthanasia". An historian favoring the right-to-die
would have selected different facts to include
and would have presented everything with an opposite tone of voice.

For example,
Dowbiggin frequently notes
that people who favor the right-to-diealso favor of such godless
things as evolutionary theory and abortion.Nazi atrocities are associated
with the "euthanasia" movement. One reason God appears in the title is
that Dowbigginbelieves that traditional religions
will always oppose the right-to-die.

Nevertheless, advocates of the
right-to-die should read this book
to feel the assumptions
operating in the minds of the opposition.

If proposed right-to-die laws used a completely different
expression,
this might have been a completely different book.
If we outlaw 'causing
premature death', then everyone can agree:
We do not want anyone to end his or her life before its proper time.
And we certainly do not want physicians
to
help us 'commit suicide'.

The basic context for this book is
the United Kingdom,but the author also refers to
right-to-die thinking in other parts of the
English-speaking world.

The arguments against foolishly ending one's own life are well taken, but the author does not tell us
how he plans to meet his own death. Will he resist any discussion of
medical choices that would shorten his process of
dying?